Mona A ABDELRAHMAN, Ashraf GENİNA, Amira S. A. SAİD, Mohamed E. A. ABDELRAHİ

Efficacy and safety of combined vs. single renin-angiotensin-aldosterone system blockade in chronic kidney disease

Hypertension and proteinuria are well-known predictors of chronic kidney disease (CKD) progression. Therapeutic interventions have different magnitude of albuminuria and hypertension. This study was designed to evaluate the efficacy and safety of combined vs. single renin-angiotensin-aldosterone system (RAAS) blockade in chronic kidney disease. Forty (28 female) patients with chronic kidney diseases were collected from nephrology outpatient clinic, internal medicine department, Beni Suef University hospital. They were divided randomly into 2 groups. Group A was 24 (20 females) patients treated with Enalapril, as angiotensin converting enzyme inhibitor (ACE-I) alone. Group B was 16 (8 females) patients treated with combination of Enalapril and Irbesartan, as angiotensin receptor blocker (ARB). All patients were subjected to full history taking; thorough clinical examination; certain laboratory tests and renal function tests at the start of the study, 1.5 and 3 months later. Proteinuria, urinary albumin/creatinine ratio (UACR), systolic blood pressure (SBP) and glomerular filtration rate (GFR) were significantly (p

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1. Levey AS, Eckardt KU, Tsukamoto Y, Levin A, Coresh J, Rossert J, De Zeeuw D, Hostetter TH, Lameire N, Eknoyan G. Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2005;67(6):2089-100.

2. Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, Van Lente F, Levey AS. Prevalence of chronic kidney disease in the United States. JAMA. 2007;298(17):2038-47.

3. Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, Hogg RJ, Perrone RD, Lau J, Eknoyan G. National Kidney Foundation, National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003;139(2):137-47.

4. Haynes R, Mason P, Rahimi K and Landray MJ. Dual blockade of the renin–angiotensin system: are two better than one? Nephrol Dial Transplant. 2009:458.

5. Kunz R, Friedrich C, Wolbers M, and Mann JFE. Meta-analysis: effect of monotherapy and combination therapy with inhibitors of the renin–angiotensin system on proteinuria in renal disease. Ann Intern Med. 2008; 148(1): 30-48.

6. Schieppati A and Remuzzi G. The future of renoprotection: frustration and promises. Kidney Int Suppl. 2003;64(6):1947-55.

7. Remuzzi G, Perico N, Macia M, Ruggenenti P. The role of reninangiotensin-aldosterone system in the progression of chronic kidney disease. Kidney Int Suppl. 2005;68:57-65.

8. Pichler RH. and de Boer I.H. Dual renin-angiotensin-aldosterone system blockade for diabetic kidney disease. Curr Diab Rep. 2010;10(4) 297-305.

9. Susantitaphong P, Sewaralthahab K, Balk EM, Eiam-ong S, Madias NE, Jaber BL. Efficacy and safety of combined vs. single renin– angiotensin–aldosterone system blockade in chronic kidney disease: a meta-analysis. Am J Hypertens. 2013;26(3):424-41.

10. Taler SJ, Agarwal R , Bakris GL , Flynn JT, Nilsson PM, Rahman M, Sanders PW, Textor SC, Weir MR, Townsend RR. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for management of blood pressure in CKD. AJKD. 2013;62(2):201-13.

11. James PA, Oparil S, Carter BL, Cushman WC, DennisonHimmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC, Svetkey LP, Taler SJ, Townsend RR, Wright JT, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5):507-20.

12. Molitch ME, Adler AI, Flyvbjerg A, Nelson RG, So W-Y, Wanner C, Mogensen CE. Diabetic kidney disease: a clinical update from Kidney Disease: Improving Global Outcomes. Kidney Int. 2015;87(1):20-30.

13. Mogensen CE, Neldam S, Tikkanen I, Oren S, Viskoper R, Watts RW and Cooper ME. Randomised controlled trial of dual blockade of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study. BMJ. 2000;321(7274):1440-4.

14. Ligtenberg G, Blankestijn PJ, Oey PL, Klein IH, Dijkhorst-Oei LT, Boomsma F, and Koomans HA. Reduction of sympathetic hyperactivity by enalapril in patients with chronic renal failure. New Engl J Med. 1999;340(17):1321-8.

15. Andersen NH, Poulsen PL, Knudsen ST, Poulsen SH, Eiskjær H, Hansen KW, Helleberg K, and Mogensen CE. Long-Term Dual Blockade With Candesartan and Lisinopril in Hypertensive Patients With Diabetes The CALM II study. Diabetes Care. 2005;28(2):273-7.

16. Mann JF, Schmieder RE, McQueen M, Dyal L, Schumacher H, Pogue J, Wang X, Maggioni A, Budaj A, Chaithiraphan S, Dickstein K, Keltai M, Metsärinne K, Oto A, Parkhomenko A, Piegas LS, Svendsen TL, Teo KK, Yusuf S, Ontarget investigators. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. The Lancet. 2008;372(9638):547-53.

17. Bunke M, and B Ganzel. Effect of calcium channel antagonists on renal function in hypertensive heart transplant recipients. J Heart Lung Transplant. 1991;11(6):1194-9.

18. Mercier K, Smith H, and Biederman J. Renin-AngiotensinAldosterone System Inhibition: Overview of the Therapeutic Use of Angiotensin-Converting Enzyme Inhibitors, Angiotensin Receptor Blockers, Mineralocorticoid Receptor Antagonists, and Direct Renin Inhibitors. Prim Care. 2014;41(4):765-78.

19. Ruggenenti P, Fassi A, Ilieva AP, Bruno S, Iliev IP, Brusegan V, Rubis N, Gherardi G, Arnoldi F, Ganeva M, Ene-Iordache B, Gaspari F, Perna A, Bossi A, Trevisan R, Dodesini AR, Remuzzi G. Bergamo Nephrologic Diabetes Complications Trial (BENEDICT) Investigators. Preventing microalbuminuria in type 2 diabetes. N Engl J Med. 2004;351(19):1941-51.

20. Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, Remuzzi G, Snapinn SM, Zhang Z, Shahinfar S. RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345(12):861-9.

21. Parving HH, Lehnert H, Bröchner-Mortensen J, Gomis R, Andersen S, Arner P., et al. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med. 2001;345(12):870-8.

22. Viberti G, and Wheeldon NM. Microalbuminuria reduction with valsartan in patients with type 2 diabetes mellitus a blood pressure– independent effect. Circulation. 2002;106(6):672-8.

23. De Zeeuw D, Remuzzi G, Parving HH, Keane WF, Zhang Z, Shahinfar S, Snapinn S, Cooper ME, Mitch WE, Brenner BM. Albuminuria, a therapeutic target for cardiovascular protection in type 2 diabetic patients with nephropathy. Circulation. 2004;110(8):921-7.

24. Maqsood K, Siddiqui A, and Teehan G. Antihypertensive Therapy in Non-Diabetic Chronic Kidney Disease Associated with Proteinuria in Adults. OJNeph. 2013;3(03):128.

25. Hirsch JS, Drexler Y, and Bomback AS. Aldosterone blockade in chronic kidney disease. Sem Nephrol. 2014;34(3):307-22.

26. Menne J, Ritz E, Ruilope LM. The Randomized Olmesartan and Diabetes Microalbuminuria Prevention (ROADMAP) Observational Follow‐Up Study: Benefits of RAS Blockade With Olmesartan Treatment Are Sustained After Study Discontinuation. J Am Heart Assoc. 2014;3(2):e000810.

27. Chan GC, and Tang SC. Diabetic nephropathy: landmark clinical trials and tribulations. Nephrol Dial Transpl. 2015; 411.

28. Makino H, Haneda M, Babazono T, Moriya T, Ito S, Iwamoto Y, Kawamori R, Takeuchi M, Katayama S; INNOVATION Study Group., Prevention of transition from incipient to overt nephropathy with telmisartan in patients with type 2 diabetes. Diabetes Care. 2007;30(6):1577-8.

29. Haller H, Ito S, Izzo JL, Januszewicz A, Katayama S, Menne J, Mimran A, Rabelink TJ, Ritz E, Ruilope LM, Rump LC, and Viberti G. For the ROADMAP Trial Investigators, Olmesartan for the delay or prevention of microalbuminuria in type 2 diabetes. N Engl J Med. 2011;364(10) 907-17.

30. Lovshin JA, and lssac Cherney DZ. Can two be better than one? Dual RAS blockade in patients with type 2 diabetes and overt nephropathy in the age of ONTARGET and ALTITUDE. Hypertens Res. 2014;37(1) 4-6.Jhund PS, McMurray JJ, Chaturvedi N, Brunel P, Desai AS, Finn PV, Haffner SM, Solomon SD, Weinrauch LA, Claggett BL, Pfeffer MA. Mortality following a cardiovascular or renal event in patients with type 2 diabetes in the ALTITUDE trial. Eur Heart J. 2015;36(36):2463-9.

31. Rutkowski B, and Tylicki L. Nephroprotective Action of ReninAngiotensin-Aldosterone System Blockade in Chronic Kidney Disease Patients: The Landscape After ALTITUDE and VA NEPHRON-D Trails. J Ren Nutr. 2015;25(2):194-200.

32. Li PK, Kwan BC, how KM, Leung CB, Szeto CC. Treatment of early immunoglobulin A nephropathy by angiotensin-converting enzyme inhibitor. Am J Med. 2013; 126(2): 162-8.